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I <br /> Safety and Build s ivision <br /> -�■■ SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> �`�■� 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P_0-Box 7969 <br /> Madison,Wl 53707-7969 <br /> • A:tach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x t t inches in size. <br /> State Sanita Permit Number <br /> • See reverse side for instructions for completing this application ��036 �ff(6� <br /> The information you provide may be used by other government agency programs ❑`Check it rev, ion to previous application O <br /> [Privacy Laws. 15.04(1)(m)I- State Plan LD Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF IRMATIONProperty ocation <br /> 4erylner Name 1/4 1/4 $ l T O ,N, R E(or)W <br /> ner's Mail Address Lot Number lockI Number <br /> �1 1 <br /> �� Zinc de JZ_ Phone Number Subdlyisiont�Nam�e o�SM Num er <br /> ( ) (� 901 <br /> y Nearest Road y <br /> BUILDING: (check one) ❑ State Owned ° vlage !i�_ <br /> blic 1 or 2 Family Dwelling- No.of bedrooms 2 Town of AKLA <br /> ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground ❑ 11 Restaurant/Bar/Dining <br /> 7 Merchandise: Sales/Repairs ❑ <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1 New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> � S stem --System ---_______ Tankonly --------------ExistingSyst m-------------Existing System <br /> —SSSS y----SSSS-- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Nom Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate System Elev. 7. Final Grade <br /> Required (sq. ft-) Proposed(sq.ft.) (Ga[s/day/sq.ft.) (Min./inch) Elevation <br /> 300 Z 1 32 �] q3.-Z- Feet 9,5. 7 Feet <br /> VII. TANK Capacity ite <br /> in gallons Total #of Manufacturer's Name Prefab on- Steel Fiber- Plastic Aper <br /> INFORMATION New Existin Gallons Tanks Concrete st ucted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank I 1:1 ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,RESPONSIBILITY <br /> assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Si nature (No tamps) MP/MPRSW No.: Business Phone Number <br /> Plumber's Name:(Pant) 9 - <br /> IC S <br /> P umber's Address(Street,City,St te,Zip Code): <br /> rL w o / <br /> IX. COUNTY/ DEPARTME T USE ONLY <br /> Disapproved Sanitary Permit °ec`9 rouNdwaler aessue Issuing <br /> 05 ps) <br /> ee <br /> `-YA4J}T urlya feel � <br /> (Approved ❑Owner Given Initial XJ Qs <br /> iT\ Adverse Determination 't-' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: A/0 rweowt <br /> SND igiwim-4398111.OY94) MTRIBUTION. c C-0,.0— <br /> <oPY To: 5�letyBBull.lhvp Dio,.imi3Owne,Pu <br /> W, <br />